Pennsylvania health systems sue Aetna claiming breach of contract 

Photo: Porter Gifford Retired Contributor/Getty Images

Bridges Health Partners has filed a lawsuit against Aetna Network Services, citing multiple breach-of-contract claims from its 2023 agreement. 

Bridges is made up of three independent nonprofit health systems in the Pittsburgh metropolitan market and surrounding communities, including Independence Health System, St. Clair Health and Washington Health System. 

The complaint alleges Aetna used funds that should have gone back to the health systems to give Medicare Advantage members supplemental benefits. Bridges did not agree to this arrangement and has no control over Aetna's spending, according to a released statement from Dr. Robert Zimmerman, Bridges Health Partners president and CMO. 

Bridges filed the lawsuit to prohibit Aetna from incorrectly allocating the cost of supplemental benefits to Bridges providers under the 2023 agreement, Zimmerman said. 

The complaint was filed Tuesday in the Pennsylvania State Court of Common Pleas of Allegheny County for declaratory and injunctive relief. 

WHY THIS MATTERS

The supplemental benefits Aetna offers are used solely to gain new memberships and will impede the care given at a Bridges' provider by taking away monies allocated to treating patients, according to Zimmerman. 

While the programs can be attractive marketing initiatives, they do impact Bridges' ability to maintain the quality of care they currently offer their patients, Zimmerman said. 

The original agreement with Aetna was designed to enhance the quality of care for patients while decreasing the overall cost to Aetna members that receive treatment at Bridges Health Partners providers, he said. Aetna would reward Bridges by sharing in the cost savings that is below a specified medical cost target and provide additional payments for meeting the agreed upon quality metrics. 

Instead of paying what was due, Aetna loaded in supplemental benefit costs such as marketing expenses that included gift cards, over-the-counter medications, meals, gym memberships and more, according to the complaint.

Incentives like the free gift cards and over-the-counter medications are available only through CVS, Aetna's parent company, Zimmerman said. 

"When we opened our doors in 2017, we made it our mission to improve the health of the people in our communities by providing high-quality, cost-effective, patient-centered care all led by physicians," Zimmerman said. "While the incentives are good programs, they are not critical care health programs. They are supplemental programs that potentially erode a patient's care at our providers. If we have to pay for the incentives, we cannot provide cost-saving, patient-centered care. It's egregious manipulation but also a breach of our contract with Aetna."

THE LARGER TREND

The agreement with Aetna should have worked to stem margin declines from the value-based model, according to Zimmerman. 

"Our recent experience with Aetna shows the health plans manipulating their CMS funding to use value-based programs to boost their corporate profits to the detriment of providers," Bridges said by statement. 

Bridges Health Partners is a network of 60-plus specialty providers, eight acute care hospitals, 100-plus  ambulatory facilities and more than 400 primary care physicians.

St. Clair Health, Washington Health System, and Independence Health System. to date have saved millions of dollars that they pass along to their patients in reduced costs, Bridges said. 

ON THE RECORD

John Grese, Bridges Health Partners vice president of administration said, "Health plan organizations, like Aetna, are setting record profits while community-based hospitals and health systems are struggling. This is a national crisis. If the insurance agency corporate giants are not stopped, community health care will be obsolete, putting thousands of doctors, nurses, and staff out of jobs and the very people needing treatment will be the ones who suffer." 

Email the writer: SMorse@himss.org